Busy on-call.
Wait, when has it ever been free?
Never mind.
Call from A&E with a referral for a patient with GCS 3 with bilaterally reactive pupils.
One look at the scan by a junior doctor could tell you what the problem was. Fischer IV SAH with intraparenchymal clot.
I ran straight to theatre to speak to my consultant. I put the scans up. I told him
“54 year old, Fischer IV SAH, collapsed at Canary Wharf 15 mins ago, bilaterally pupils reactive. She needs to go to theatre for an evacuation and clipping.”
He turns around and throws one look at the scan and says I’m doing it.
I did a fast team brief and said everything that I wanted. Slowly, it came to me that I was talking out of reflex but I didn’t know what instruments he specifically wanted for the clipping because I had never even assisted an aneurysm.
After running around like headless chickens for about 20 minutes, patient was up in theatre.
10 minutes into the surgery, we saw where the bleed was coming from. We saw what had ruptured. In front of me flashed vessels that I had seen and learnt about year in and out on textbooks. Anatomy was confusing but there it was elegantly lying in front of us, all prepared to put up a fight with us. I began to absorb it all.
Before I could take my next breath, a gush of blood started to pour out. The amount of blood in front of my eyes was unbelievable. Even as I write this, a day and 2 hours after the event, the blood that was flashing in front of my eyes under the microscope, still gives me the surmount of adrenaline that I felt when I was standing in theatre.
There was nothing I could do. The consultant said, “Anna”, (our anesthetist), “the aneurysm has ruptured. Can you bring the systolic blood pressure to 60 because I need to control this bleeding”. He wasn’t shaking. He wasn’t panicking. He was in his element. I wasn’t breathing or I forgot how to. Don’t know which one.
“Patties. Patties. More patties.”
More pressure went on to the aneurysm to control it. To enable him to see how to control it. A minute and a half later, the temporary clip ever so delicately placed on to the internal carotid artery. The hose of blood stopped. That gush stopped. The timer started. 2 mins of countdown by which time he had to clip this monster of an aneurysm that was waiting to smear our faces with blood again. The years of experience spoke through his fingers when he clipped the angry beast in under 2 mins. I felt myself taking the biggest breath I ever had. Very so gently, my consultant stepped back from the microscope, looked at me, “So would you consider Neurovascular?”.
I was smiling so much that I couldn’t even control it, even behind the mask. It was pure sheer skill that was flabbergasting.
Upon further dissection lay our friendly neighbor, the tri-lobed MCA aneurysm at the junction of the 2 M2’s. He was talking me through the procedure of how the clip applicator works and how the proximal supply is occluded in order to clip the distal segment aneurysm and all of that. I was watching with close intent and was absorbing everything. From how his hand held the instrument and how he supported his hand to literally whatever detail I could grasp because god knows how long it would be till I see another one.
He then said, “Do you want to put the temporary clip on the MCA?”.
Was I frightened? Yes!
Was I scared to do it? 100%
Did I think I could do it? Yes. If at any point I wasn’t comfortable, I was ready to accept it and step back and say no this is not for me. But I didn’t.
There I stood with the clip applicator in one hand very slowly doing what he had told me to do. It worked. First time, second time.
I was truly grateful he had even let me touch the MCA. THE middle cerebral artery. Whilst I was processing how beautiful this process has been, he was slowly working on the posterior aspects of the large aneurysm in order to be able to clip it.
Once that was done, he turned around and said, “Think you can do it?”
I didn’t think for a second before I replied “Yes!”
I stepped up on my little footstool and saw the aneurysm through the microscope. I took a deep breath in and applied the clip. It was my very first clipping of an aneurysm. I stepped back and gave the instruments to him and jumped up in the air for a second before I could calm myself down.
The Soul Of A Surgeon 